Musculoskeletal Disorders of the feet

Disorders of Feet

Maria Carmela L. Domocmat, RN, MSN
Instructor
Northern Luzon Adventist College

2

Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Overview
• Part 1: Degenerative & Metabolic bone
disorders:
• Part 2: Bone infections
• Part 3: Muscular disorders
• Part 4: Disorders of the hand
• Part 5: Spinal column deformities
• Part 6 : Disorders of feet
• Part 7: Sports Injuries

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Disorders of Feet
• Hallux valgus (bunions)
• Morton’s neuroma (plantar neuroma)
• Hammer toe
• Tarsal tunnel syndrome
• Plantar Fasciitis
• Corn
• Callus
• Ingrown Nail
• Hypertrophic Ungual Labium

4


Disorders of Feet
• Hallux valgus (bunions), Morton’s neuroma
(plantar neuroma), Hammer toe , Tarsal tunnel
syndrome , Plantar Fasciitis, Corn, Callus,
Ingrown Nail, Hypertrophic Ungual Labium

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http://familyfootcarenj.com/web/images/layout/conditions_map.jpg

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Hallux valgus
• is a condition that affects the joint at the base of
the big toe.
• The condition is commonly called a bunion.
▫ bunion - refers to the bump that grows on the side
of the first metatarsophalangeal (MTP) joint.

9


Hallux valgus (bunion)
• The deformity involves the big toe and the long
bone behind the big toe, the 1st metatarsal.
• Over time, the 1st metatarsal will begin to move
towards the other foot (medial) while the big toe
will move out of joint towards the 2nd toe
(lateral).

http://www.footankleinstitute.com/hallux-valgus-bunion-surgery/

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• As the end of the 1st metatarsal bone begins to
stick out, it will be under pressure from shoes
and the ground.
• this constant pressure and friction will cause
extra bone formation, leading to the bump that
is seen on the side of the foot.


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• The big toe will continue to shift towards the
second toe causing an unbalanced big toe joint.
Over time arthritis can develop in the joint due
to the mal-positioned joint.
• A bunion deformity is always progressive. It will
always get worse over time.


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• term hallux valgus actually describes what
happens to the big toe.
▫ Hallux - medical term for big toe
▫ Valgus - anatomic term that means the deformity
goes in a direction away from the midline of the
body.
• hallux valgus - big toe begins to point towards
the outside of the foot.
▫ As this condition worsens, other changes occur in
the foot that increase the problem.

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Etiology
• Contrary to common belief,
▫ high-heeled shoes with a small toe box or tight-
fitting shoes do not cause hallux valgus.
▫ such footwear does keep the hallux in an abducted
position if hallux valgus is present, causing
mechanical stretch and deviation of the medial
soft tissue.
▫ In addition, tight shoes can cause medial bump
pain and nerve entrapment.

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Etiology
• Biomechanical instability
• Arthritic/metabolic conditions
• Structural deformity
• Neuromuscular disease
• Traumatic compromise

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Etiology
▫ most common yet most difficult to understand etiology
▫ Contributing factors, if present, include
gastrocnemius or gastrocsoleus equinus,
flexible or rigid pes plano valgus,
rigid or flexible forefoot varus,
dorsiflexed first ray,
hypermobility, or
short first metatarsal.
Most often, excessive pronation at the midtarsal and
subtalar joints compensates for these factors throughout
the gait cycle.

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Etiology
▫ Some pronation must occur in gait to absorb
ground-reactive forces. However, excessive
pronation produces too much midfoot mobility,
which decreases stability and prevents
resupination and creation of a rigid lever arm;
these effects make propulsion difficult.

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Etiology
▫ During normal propulsion
approximately 65° of dorsiflexion is necessary at the first
metatarsophalangeal joint,
only 20-30° is available from hallux dorsiflexion.
Therefore, the first metatarsal must plantarflex at the sesamoid
complex to gain the additional 40° of motion needed.
Failure to attain the full 65° because of jamming of the joint
during pronation subjects the first metatarsophalangeal to
intense forces from which hallux valgus develops.
▫ If the foot is sufficiently hypermobile as a result of excessive
pronation, the metatarsal tends to drift medially and the
hallux drifts laterally, producing hallux valgus. If no
hypermobility is present, hallux rigidus develops instead.

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Etiology
Arthritic/metabolic
Structural deformity
conditions
▫ Gouty arthritis • Malalignment of articular
▫ Rheumatoid arthritis surface or metatarsal shaft
▫ Psoriatic arthritis • Abnormal metatarsal length
▫ Connective tissue disorders • Metatarsus primus elevatus
such as Ehlers-Danlos • External tibial torsion
syndrome, Marfan • Genu varum or valgum
syndrome, Down syndrome, • Femoral retrotorsion
and ligamentous laxity

21 3/5/2012

Etiology
Neuromuscular disease Traumatic compromise
• Multiple sclerosis • Malunions
• Charcot-Marie-Tooth disease • Intra-articular damage
• Cerebral palsy • Soft-tissue sprains
• Dislocations

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Symptoms
• Symptoms of Hallux valgus depending on
the degree of severity:
▫ Aesthetic problem.
▫ Formation of calluses, chronic irritation of the
skin and bursa.
▫ Increasing pain under load and when moving.
▫ Progressive arthrosis and stiffening in the base
joint of the toe.
▫ Corollary deformities such as hammer and claw
http://www.hallufix.org/english/hallux_valgus.html

toe.

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Types of Hallux valgus
Degree 1 Degree 2
• Toe malpositioning below 20 • Malpositioning between 20
degrees. No symptoms. and 30 degrees. Occasional
pain.


Types of Hallux valgus
Degree 3 Degree 4
• Malpositioning between 30 • Severest form with
and 50 degrees. Regular pain. malpositionings over 50
Increasing restraints on degrees and painful restraints
activities. Pronounced on the activities of everyday
malpositioning! life.
Surgical treatment

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Treatment
• Medical Therapy
▫ Adapting footwear
▫ Pharmacologic or physical therapy
▫ Functional orthotic therapy
• Surgical Therapy
▫ Capsulotendon balancing or exostectomy
▫ Osteotomy
▫ Resectional arthroplasty
▫ Resectional arthroplasty with implant
▫ First metatarsophalangeal joint arthrodesis
▫ First metatarsocuneiform joint arthrodesis

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Bunionectomy
• remove the bump that makes up the bunion.
• performed through a small incision on the side of the foot immediately over
the area of the bunion.
• Once the skin is opened the bump is removed using a special surgical saw or
chisel.
• The bone is smoothed of all rough edges and the skin incision is closed with
small stitches.
• It is more likely that realignment of the big toe will also be necessary. The
major decision that must be made is whether or not the metatarsal bone
will need to be cut and realigned as well. The angle made between the first
metatarsal and the second metatarsal is used to make this decision. The
normal angle is around nine or ten degrees. If the angle is 13 degrees or
more, the metatarsal will probably need to be cut and realigned.
• When a surgeon cuts and repositions a bone, it is referred to as
an osteotomy. There are two basic techniques used to perform an
osteotomy to realign the first metatarsal.

http://www.concordortho.com/patient-education/topic-detail-
popup.aspx?topicID=a5cea3a8a6d8093483657c959125dbaf

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Distal Osteotomy
• the far end of the bone is cut and moved laterally
• This effectively reduces the angle between the first
and second metatarsal bones.
• usually requires one or two small incisions in the
foot.
• Once the surgeon is satisfied with the position of the
bones, the osteotomy is held in the desired position
with one, or several,metal pins.
• Once the bone heals, the pin is removed. The metal
pins are usually removed between three and six
weeks following surgery.

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Proximal Osteotomy
• the first metatarsal is cut at the near end of the bone
• usually requires two or three small incisions in the foot.
• Once the skin is opened the surgeon performs the osteotomy. The bone is
then realigned and held in place with metal pins until it heals. Again, this
reduces the angle between the first and second metatarsal bones.
• Realignment of the big toe is then done by releasing the tight structures on
the lateral, or outer, side of the first MTP joint. This includes the tight joint
capsule and the tendon of the adductor hallucis muscle. This muscle tends
to pull the big toe inward. By releasing the tendon, the toe is no longer
pulled out of alignment. The toe is realigned and the joint capsule on the
side of the big toe closest to the other toe is tightened to keep the toe
straight, or balanced.
• Once the surgeon is satisfied that the toe is straight and well balanced, the
skin incisions are closed with small stitches. A bulky bandage is applied to
the foot before you are returned to the recovery room.


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Good footwear is often all that is
needed
• Wearing good footwear does not cure the deformity but may
ease symptoms of pain and discomfort. Ideally, get advice
about footwear from a podiatrist or chiropodist.
Advice may include:
• Wear shoes, trainers or slippers that fit well and are roomy.
• Don't wear high-heeled, pointed or tight shoes.
• You might find that shoes with laces or straps are best, as they
can be adjusted to the width of your foot.
• Padding over the bunion may help, as may ice packs.
• Devices which help to straighten the toe (orthoses) are still
occasionally recommended, although trials investigating their
use have not found them much better than no treatment at all.
http://www.patient.co.uk/health/Bunions-(Hallux-Valgus).htm

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How to Choose Shoes
1. Know your foot.
Take a look at your old shoes. Look at what areas the
most worn out shoes. A well-chosen shoes will help
to endure the physical stress well. One way to
determine your foot's shape is to do a "wet test"---
wet your foot, step on a piece of brown paper and
trace your footprint. Or just look at where your last
pair of shoes shows the most wear.
2. Don't buy uncomfortable shoes even if they are hot!
3. Ideally, you should avoid wearing heels
4. Don't make shoes multitask.
http://hallux-valgus-
rigidus.com/index.php?option=com_content&view=article&id=74&Itemid=88

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How to Choose Shoes
5. Knowing your foot's particular quirks is key to
selecting the right pair of shoes.
6. You must find shoes with well cushioned soles and
ideally, some type of soft arch-support.
7. 7. Measure your foot frequently. Foot size changes
as we get older.
8. 8. You should not buy shoes in the morning. The
size of our feet at night more than in the morning.
Feet swell over the course of the day; they also
expand while you run or walk, so shoes should fit
your feet when they're at their largest.

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How to Choose Shoes
9. Always buy shoes to fit the larger or wider foot.
Buy well-fitting shoes with a wide toe box.
10. Use bunion shields, bunion pads or bunion cushions to
protect the bunion when wearing shoes. A bunion sleeve can
be especially effective at relieving shoe pressure when walking
with a hallux valgus.
11. Utilize an orthotic device or insert, such as a bunion splint or
bunion brace, to redistribute the pressure along the arch and
ball of the foot and control the separation of the bones. These
devices help support your foot and reduce the tendency
toward hallux valgus formation.
12. Use a bunion regulator to stretch tight tendons and toe
muscles overnight – especially if you want to avoid surgery.

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Resectional arthroplasty
• is a joint-destructive procedure
• most commonly reserved for elderly patients
with advanced degenerative joint disease and
significant limitation of motion.
• The typical resectional arthroplasty that is
performed is known as a Keller procedure.

http://emedicine.medscape.com/article/1232902-treatment#showall

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Resectional arthroplasty
• performed when morbidity might be increased with
the more aggressive osteotomy that would otherwise
be selected.
• The procedure includes resection of the base of the
proximal phalanx with reapproximation of the
abductor and adductor tendon groups.
• The technique is inherently unstable and should be
used judiciously.
• The postoperative course includes limited-to-full
weight bearing in a surgical shoe immediately after
the procedure.

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Resectional arthroplasty with
implant
• is the same procedure as the resectional
arthroplasty, with similar indications, but
stability is markedly improved with the addition
of the total implant.


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Resectional arthroplasty with
implant
• Preoperative radiograph shows • Postoperative radiograph
degenerative joint disease. obtained after resectional
arthroplasty and total joint
implant placement.


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First metatarsophalangeal joint
arthrodesis
• is a joint-destructive procedure that offers a
higher degree of stability and functionality.
• considered the definitive procedure for
degenerative joint disease.
• results in complete loss of motion at the first
metatarsophalangeal joint and is reserved for
patients with high activity levels and functional
demands.

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First metatarsophalangeal joint
arthrodesis
• Preoperative radiograph shows • Postoperative radiograph show
arthrodesis. arthrodesis.

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First metatarsocuneiform joint
arthrodesis
• Significant and/or hypermobile hallux
abductovalgus may be reduced with arthrodesis
of the first metatarsocuneiform joint (see images
below).
• Indications include metatarsus primus varus,
hypermobility of the first ray, metatarsalgia of
the lesser metatarsals, and degenerative joint
disease of the metatarsocuneiform joint.

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First metatarsocuneiform joint
arthrodesis
• Preoperative radiograph shows • Postoperative radiograph
a hypermobile first ray. shows arthrodesis of the first
metatarsocuneiform.

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Marfan syndrome (MFS)
• is a spectrum disorder caused by a heritable
genetic defect of connective tissue that has an
autosomal dominant mode of transmission
• The defect itself has been isolated to
the FBN1 gene on chromosome 15, which codes
for the connective tissue protein fibrillin.
• Abnormalities in this protein cause a myriad of
distinct clinical problems, of which the
musculoskeletal, cardiac, and ocular system
problems predominate.

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• The skeleton of patients with MFS typically
displays multiple deformities including
arachnodactyly (ie, abnormally long and thin
digits), dolichostenomelia (ie, long limbs relative
to trunk length), pectus deformities (ie, pectus
excavatum and pectus carinatum), and
thoracolumbar scoliosis

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• In the cardiovascular system, aortic
dilatation, aortic regurgitation, and aneurysms
are the most worrisome clinical findings. Mitral
valve prolapse that requires valve replacement
can occur as well. Ocular findings
include myopia,cataracts, retinal detachment
and superior dislocation of the lens


50 3/5/2012

pectus carinatum pectus excavatum

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Genetics of Ehlers-Danlos Syndrome
• Ehlers-Danlos family of disorders is a group of
related conditions that share a common decrease
in the tensile strength and integrity of the skin,
joints, and other connective tissues.

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Genetics of Ehlers-Danlos Syndrome
• The first detailed clinical description of the
syndrome is attributed to Tschernogobow in 1892.
• The syndrome derives its name from reports by
Edward Ehlers, a Danish dermatologist, in 1901 and
by Henri-Alexandre Danlos, a French physician with
expertise in chemistry of skin disorders, in 1908.
• These 2 physicians combined the pertinent features
of the condition and accurately delineated the
phenotype of this group of disorders.

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Ehlers-Danlos syndrome
• The amazing, almost unnatural, contortions that
some patients with Ehlers-Danlos syndrome can
perform often arouse curiosity.
• Historically, some patients with Ehlers-Danlos
syndrome displayed the maneuvers publically in
circuses, shows, and performance tours.

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• Some achieved modest degrees of fame and bore
titles such as "The India Rubber Man," "The
Elastic Lady," and "The Human Pretzel."
• Such clinical features also raise suspicion of the
diagnosis when identified upon physical
examination.
• Unfortunately, patients often go many years
before being diagnosed

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• Patient with Ehlers-Danlos • Patient with Ehlers-Danlos
syndrome mitis. syndrome. Note the abnormal
• Joint hypermobility is less ability to elevate the right toe.
intense than with other
conditions.

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• Girl with Ehlers-Danlos
syndrome.
• Dorsiflexion of all the fingers
is easy and absolutely painless.

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• All forms of Ehlers-Danlos syndrome share the
following primary features to varying degrees:
▫ Skin hyperextensibility
▫ Joint hypermobility and excessive dislocations
▫ Tissue fragility
▫ Poor wound healing, leading to wide thin scars:
The classic description of abnormal scar formation
in Ehlers-Danlos syndrome is "cigarette paper
scars."
▫ Easy bruising

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Type Inheritan PreviousMaria Carmela L. Domocmat, RN, MSN 3/5/2012
Major Minor Diagnostic
ce Nomencla Diagnostic Criteria
ture Criteria

Kypho- Auto- Type VI – Joint laxity, Tissue fragility,
scoliosis somal lysyl severe easy bruising,
recessive hydroxyla hypotonia at arterial rupture,
se birth, scoliosis, marfanoid,
deficiency progressive microcornea,
scleral fragility osteopenia,
or rupture of positive family
globe history (affected
sibling)

59

Type Inheritance Previous Major Diagnostic Minor Diagnostic
Nomenclatur Criteria Criteria
e
Arthro Autosomal Type VII A, B Congenital Skin
chalasi dominant bilateral hyperextensibility,
a dislocated hips, tissue fragility with
severe joint atrophic scars, muscle
hypermobility, hypotonia,
recurrent easy bruising,
subluxations kyphoscoliosis, mild
osteopenia

Derma Autosomal Type VII C Severe skin Soft, doughy skin;
tospara recessive fragility; saggy, easy bruising;
xis redundant skin premature rupture of
membranes; hernias
(umbilical and
inguinal)

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Type Inheritan Previous Major Diagnostic Criteria Minor Diagnostic Criteria
ce Nomenclatu
re
Classic Autoso Types I and Skin Smooth, velvety skin;
mal II hyperextensibility, easy bruising;
domina molluscoid
nt pseudotumors;
subcutaneous
wide atrophic scars, spheroids; joint
joint hypermobility hypermobility; muscle
hypotonia;
postoperative
complication
(eg, hernia); positive
family history;
manifestations of
tissue fragility (eg,
hernia, prolapse)

61

Type Inherita Previous Major Diagnostic Minor Diagnostic
nce Nomenclat Criteria Criteria
ure
Hyperm Autoso Type III Skin involvement (soft, Recurrent joint
obility mal smooth and velvety), dislocation; chronic
domina joint hypermobility joint pain, limb pain,
nt or both; positive family
history
Vascular Autoso Type IV Thin, translucent skin; Acrogeria,
mal arterial/intestinal hypermobile small
domina fragility or rupture; joints; tendon/muscle
nt extensive bruising; rupture; clubfoot; early
characteristic facial onset varicose veins;
appearance arteriovenous, carotid-
cavernous sinus fistula;
pneumothorax;
gingival recession;
positive family history;
sudden death in close
relative

62


Down syndrome
• Down syndrome is by far the most common
and best known chromosomal disorder in
humans and the most common cause of
intellectual disability.
• Mental retardation, dysmorphic facial features,
and other distinctive phenotypic traits
characterize the syndrome

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Corn
• induration and thickening of skin
caused by friction and pressure,
painful conical mass
• appear as a horny thickening of the
skin on the toes.
• this thickening appears as a cone
shaped mass pointing down into
the skin.

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Types of Corn
o Hard corns
most common
are concentrated areas of dry, hardened skin
about the size of a pea
usually located on the outer surface of the little
toe or on the upper surface of the other toes,
but can occur between the toes
may develop within a broader area of callused
skin
sometimes called digital corns

67


Types of Corn
o Soft corns
are white and rubbery
can be extremely painful and tend to develop
between toes
are like hard corns that have been softened by
continual exposure to moisture, usually because
you don’t dry between toes properly or from sweat.
may form opposite one another and are known as
‘kissing lesions’.
Sometimes, soft corns can become infected by
bacteria or fungi.

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Other, rarer types of corn include:
• seed corns
▫ may appear as one corn or as clusters of small
corns on the bottom foot; they are usually
painless
• vascular corns
▫ occur in blood vessels and bleed if cut
• fibrous corns
▫ are corns that have been around for a long time
and have become attached to the deeper layers
of your skin, sometimes causing pain

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Causes of corns
o Corns are caused by constant pressure on a
bony area of foot. This can happen for a
number of different reasons. These include:
poorly fitting footwear – for example, shoes that
are too small, cramp toes or have uneven soles;
this is the most common cause of corns
being very active – doing lots of exercise can put
pressure on feet
prominent bones – these can press against shoes

70


Causes of corns
o Corns are caused by constant pressure on a
bony area of foot. This can happen for a
number of different reasons. These include:
a misshapen foot because foot or toes have
developed unusually –may have a toe that is
overly curved or a particular bone that is too short
poorly healed fractures – if have broken a toe or
another bone in foot, it may have set out of place
causing foot to press against shoe

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Corn
• Treatment:
• surgical removal by podiatrist

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Prevention of corns
o wearing sensible, low-heeled footwear
(maximum 4cm heel) with a rounded toe
o not wearing slip-on shoes because these
cause feet to move forward and squash
toes
o not wearing court shoes because they
don’t support feet and can cramp toes

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Corn pad

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Prevention of corns
o drying properly between toes
o losing excess weight – this will help to
reduce pressure on feet
o If already have a corn, apply an antifungal
or antibacterial powder after washing foot
to help prevent it becoming infected.

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Callus
• flat, poorly defined mass on the sole over a
bony prominence caused by pressure
• When skin is exposed to lots of pressure or
friction, the keratin layer thickens to protect it,
and develops into a callus.
• Although calluses can cover a wide area, they
aren't usually painful.

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Callus
• Treatment:
o padding and lanolin creams
o overall good skin hygiene

79


• Self treatment or management of corns and
callus includes:
▫ following the advice of a Podiatrist
▫ proper fitting of footwear
▫ proper foot hygiene and the use of emollients to
keep the skin in good condition

80


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• Neuromas
▫ are non-cancerous growths of the nerve tissue that
develop in different parts of the body.

82


Mortons Neuroma
• affects a nerve in the foot, often times the nerve
between the third and fourth toe.
• thickens the tissue around the nerves that lead
to the toes, causing sharp, burning sensations in
the ball of the foot, as well as a numbing or
stinging feeling.
• AKA: plantar neuroma or intermetatarsal
neuroma.

83


http://www.footdoc.ca/www.FootDoc.ca/
Website_Neuroma.gif

84


• Sex
▫ The female-to-male ratio for Morton's neuroma is
5:1.

• Age
▫ The highest prevalence of Morton's neuroma is
found in patients aged 15-50 years, but the
condition may occur in any ambulatory patient.
http://emedicine.medscape.com/article/308284-clinical#showall

85


Causes
• Various factors have been implicated in the
precipitation of Morton's neuroma.
• Morton's neuroma is known to develop as a result of
chronic nerve stress and irritation, particularly with
excessive toe dorsiflexion.
• Poorly fitting and constricting shoes (ie, small toe
box) or shoes with heel lifts often contribute to
Morton's neuroma. Women who wear high-heeled
shoes for a number of years or men who are
required to wear constrictive shoe gear are at risk.

86


Causes
• A biomechanical theory of causation involves the
mechanics of the foot and ankle. For instance,
individuals with tight gastrocnemius-soleus
muscles or who excessively pronate the foot may
compensate by dorsiflexion of the metatarsals
subsequently irritating of the interdigital nerve.
• Certain activities carry increased risk of
excessive toe dorsiflexion, such as prolonged
walking, running, squatting, and demi-pointe
position in ballet.

87


Manifestations
• Obtaining an accurate history is important to
making the diagnosis of Morton's neuroma.
Possible reported findings provided by the
patient with Morton's neuroma include the
following:
• The most common presenting complaints
include pain and dysesthesias in the forefoot and
corresponding toes adjacent to the neuroma.
• Pain is described as sharp and burning, and it
may be associated with cramping.

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89


Manifestations
• Numbness often is observed in the toes adjacent to the
neuroma and seems to occur along with episodes of pain.
• Pain typically is intermittent, as episodes often occur for
minutes to hours at a time and have long intervals (ie,
weeks to months) between a single or small group of
multiple attacks.
• Some patients describe the sensation as "walking on a
marble."
• Massage of the affected area offers significant relief.
• Narrow tight high-heeled shoes aggravate the symptoms.
• Night pain is reported but is rare.

90


Dx tests
• palpable mass or a "click" between the bones.
• Doctor put pressure on the spaces between the
toe bones to try to replicate the pain and look for
calluses or evidence of stress fractures in the
bones that might be the cause of the pain.
• Range of motion tests will rule out arthritis or
joint inflammations.
• X-rays may be required to rule out a stress
fracture or arthritis of the joints that join the
toes to the foot.

91


Treatment
• Rehabilitation Program: Physical
Therapy
• Treatment strategies range from conservative to
surgical management.
• The conservative approach may benefit from the
involvement of a PT.
▫ Recommend soft-soled shoes with a wide toe box
and low heel (eg, an athletic shoe).
▫ High-heeled, narrow, nonpadded shoes should not
be worn, because they aggravate the condition.

92


Treatment
• Rehabilitation Program: PT
• conservative management
▫ to alter alignment of the metatarsal heads.
▫ One recommended action is to elevate the metatarsal
head medial and adjacent to the neuroma, thereby
preventing compression and irritation of the digital
nerve.
▫ A plantar pad is used most often for elevation. Have
the patient insert a felt or gel pad into the shoe to
achieve the desired elevation of the above metatarsal
head.

93


Treatment
• Cryotherapy
• Ultrasonography
• deep tissue massage
• stretching exercises.


94


Treatment
• Ice is beneficial to decrease the associated
inflammation.
• Phonophoresis also can be used, rather than just
ultrasonography, to further decrease pain and
inflammation.


95


Phonophoresis

96


Phonophoresis

97


Treatment
• Changes in footwear. Avoid high heels or
tight shoes, and wear wider shoes with lower
heels and a soft sole. This enables the bones to
spread out and may reduce pressure on the
nerve, giving it time to heal.
• Orthoses. Custom shoe inserts and pads also
help relieve irritation by lifting and separating
the bones, reducing the pressure on the nerve.
http://orthoinfo.aaos.org/topic.cfm?topic=a00158

98


Treatment
• Injection. One or more injections of a
corticosteroid medication can reduce the
swelling and inflammation of the nerve, bringing
some relief.
• Combination
▫ Several studies have shown that a combination
of roomier, more comfortable shoes,
nonsteroidal anti-inflammatory
medication, custom foot orthoses and
cortisone injections provide relief in over 80
percent of people with Morton's Neuroma.
http://orthoinfo.aaos.org/topic.cfm?topic=a00158

99


Surgical Intervention
• When conservative measures for Morton's neuroma are
unsuccessful, surgical excision of the area of
fibrosis in the common digital nerve may be curative.
• Common adverse outcomes include
▫ dysesthesias radiating from a painful nerve stump.
Dysesthesias may be treated as any other dysesthetic pain.
• Surgical options include the following:
▫ Neurectomy with nerve burial
▫ Transverse intermetatarsal ligament release, with
or without neurolysis
▫ Endoscopic decompression of the transverse
metatarsal ligament

100


Other Treatment
• Perform injection into the dorsal aspect of the
foot, 1-2 cm proximal to the webspace, in line
with the MTP joints.
• Advance the needle through the midwebspace
into the plantar aspect of the foot until the
needle gently tents the skin. Then withdraw it
about 1 cm to where the tip of the neuroma is
located.

101


Other Treatment
• Inject a corticosteroid/anesthetic mix. A
reasonable volume is 1 mL of corticosteroid and
2 mL of anesthetic. T
• the anesthetic used should not contain
epinephrine, as necrosis may result. Care also
should be taken not to inject into the plantar
pad.

102


Other Treatment
• Adverse outcomes include plantar fat pad
necrosis. Transient numbness of the toes also
may occur. Although many practitioners use
multiple injections, the likelihood of benefit
from subsequent injections, after failure to
achieve relief from the initial injection, is
negligible.

103


Other Treatment
• An Australian investigation using a single,
ultrasonographically guided
corticosteroid injection for Morton's
neuroma found that 9 months after treatment,
complete pain relief had occurred in 11 of the 39
neuromas studied.

104

Maria Carmela 3/5/2012

L. Domocmat,
RN, MSN

Neurectomy: typical incision location. Neurectomy: superficial exposure.

Neurectomy: deeper dissection. Neuroma and adherent fibrofatty tissue.

105


Medication Summary
• Dysesthesias may be treated as any other
dysesthetic pain.
• Tricyclic antidepressants, such as amitriptyline
at 10-25 mg PO qhs, may be tried.
• If this approach is unsuccessful, anticonvulsants
(eg, gabapentin, carbamazepine) often are
effective.

106


Tricyclic Antidepressants
• A complex group of drugs that have central and
peripheral anticholinergic effects, as well as
sedative effects. They have central effects on
pain transmission, and they block the active re-
uptake of norepinephrine and serotonin.
• Amitriptyline (Elavil)
▫ Analgesic for certain chronic and neuropathic
pain. Low doses, 10-25 mg qhs, may provide pain
relief from burning and tingling occurring at rest
but function only as an adjunct to definitive
treatment.

107


Anticonvulsants
• Use of certain antiepileptic drugs (AEDs), such as the
GABA analogue Neurontin (gabapentin), has proven
helpful in some cases of neuropathic pain. Thus,
although unstudied, a trial of such an agent might
conceivably provide analgesia for symptomatic
neuropathy. Used for dysesthesias not controlled with
definitive treatment plus tricyclic antidepressants (or in
patients unable to take tricyclic antidepressants).
• Gabapentin (Neurontin)
▫ Neuromembrane stabilizer useful in pain reduction with
dysesthetic pain. Has antineuralgic effects; however, exact
mechanism of action is unknown. Structurally related to
GABA, but does not interact with GABA receptors.

108


Anticonvulsants
• Pregabalin (Lyrica)
▫ Structural derivative of GABA. Mechanism of
action unknown. Binds with high affinity to
alpha2-delta site (a calcium channel subunit). In
vitro, reduces calcium-dependent release of
several neurotransmitters, possibly by modulating
calcium channel function. FDA approved for
neuropathic pain associated with diabetic
peripheral neuropathy or postherpetic neuralgia
and as adjunctive therapy in partial-onset
seizures.

109


Serotonin-Norepinephrine Reuptake
Inhibitors
• These agents inhibit neuronal serotonin and
norepinephrine reuptake.
• Duloxetine (Cymbalta)
▫ Description Indicated for diabetic peripheral
neuropathic pain. Potent inhibitor of neuronal
serotonin and norepinephrine reuptake

110


111


Hammer toe
• is a deformity of the toe, in which the end of the
toe is bent downward.
• usually affects the second toe. However, it may
also affect the other toes. The toe moves into a
claw-like position.

112


Hammer toe

113


Causes, incidence, and risk factors
• most common cause of hammer toe is wearing
short, narrow shoes that are too tight. The toe is
forced into a bent position. Muscles and tendons
in the toe tighten and become shorter.

114


• Hammer toe is more likely to occur in:
▫ Women who wear shoes that do not fit well or
have high heels
▫ Children who keep wearing shoes they have
outgrown
• The condition may be present at birth
(congenital) or develop over time.
• In rare cases, all of the toes are affected. This
may be caused by a problem with the nerves or
spinal cord.

115


• may be present at birth (congenital) or develop
over time.
• In rare cases, all of the toes are affected. This
may be caused by a problem with the nerves or
spinal cord.

116


Symptoms
• The middle joint of the toe is bent. The end part
of the toe bends down into a claw-like deformity.
At first, you may be able to move and straighten
the toe. Over time, you will no longer be able to
move the toe.
• A corn often forms on the top of the toe. A callus
is found on the sole of the foot.
• Walking or wearing shoes can be painful.

117


Hammer toe

118


Dx tests
• physical examination of the foot
• decreased and painful movement in the toes.

http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9360.jp
g

119


http://www.myfootshop.com/images/medical/ortho/hammer_toe_differences_mod.j
pg

120


Treatment
• Mild hammer toe in children can be treated by
manipulating and splinting the affected toe.

http://www.family-foot.com/images/hammer_toe_whatis.jpg

121


Treatment
• The following changes in footwear may help
relieve symptoms:
▫ Wear the right size shoes or shoes with wide toe
boxes for comfort, and to avoid making hammer
toe worse.
▫ Avoid high heels as much as possible.
▫ Wear soft insoles to relieve pressure on the toe.
▫ Protect the joint that is sticking out with corn pads
or felt pads

122


Treatment
• A foot doctor can make foot devices called
hammer toe regulators or straighteners for you,
or you can buy them at the store.
• Exercises may be helpful.
▫ You can try gentle stretching exercises if the toe is
not already in a fixed position.
▫ Picking up a towel with your toes can help stretch
and straighten the small muscles in the foot.

123


Treatment
• For severe hammer toe, you will need an
operation to straighten the joint.
• The surgery often involves cutting or moving
tendons and ligaments.
• Sometimes the bones on each side of the joint
need to be connected (fussed) together.
• Most of the time, you will go home on the same
day as the surgery. The toe may still be stiff
afterward, and it may be shorter.

124


Prevention and Cure of Hammer Toes
with Products
• Hammer Toe • Yoga Toes Toe
Regulator Stretcher
• Hammer Toe Cushion • Toe Rings
• Foam Toe Tubes • Toe Brace
• Gel Toe Cap • Toe Alignment Splint
• Toe Spreader • Toe Trainers
• Silicone Toe Crest • Hammer Toe
• Toe Spacer Cushion Straightener
• Digital Toe Pad

125


126


Hammer Toe Correction Bandage
• Price $14.95

127


Hammer Toe Regulator
• Toe regulator efficiently
integrates the middle joint of
toe with other joints.
• It reduces the pressure and
irritation at toe tips and region
over the toes.
• The toe regulator straightens
the joint of hammer toes (or)
claw toes with a slight and
smooth pressure.
• Toe regulator is effective for
pain relief and proper
alignment of hammer toes.

128


Hammer Toe Regulator

129


Hammer Toe Cushion
• provides ease feel over the
contracted part and comforts
Hammer toe with enough
support.
• assists for a stress free
movement and aid in lifting
the toe to normal position.
• minimizes pressure at the top
and tip of toes with a spongy
effect.
• is provided with an adjustable
toe loop for comfortable and
secure fit.

130


Foam Toe Tubes
• The soft foam present in the
tube safeguard toes from rash
rubbing against footwear.
• Foam toe tube is easy to wear
for getting effective pain relief
from hammer toes.
• It reduce the pressure and
swelling over Hammer toes for
trouble free walks.

131


Gel Toe Cap
• Gel Toe Cap softens the
Hammer toes giving excellent
cushioning to the painful
deformed toes.
• It also relieves extreme pain at
the top and tip of toes
effectively.
• Gel maintains the spongy
comfort and reduces pressure
all over the hammer toe.

132


Silicone Toe Crest
• The reinforced loop with elastic
fabric of the toe crest holds the
toe perfectly straight.
• The toe crest provides soft feel
under three toes excluding the
big and little toe.
• It relieves the pain caused by
hammer toe.
• It adds strength to the toe and
gives extra smoothness to the
affected spot.
• Silicone soothes the toe for ease
feel.
• Toe crest is durable and can be
worn comfortably with a snug
fit.

133


Toe Alignment Splint
• Toe alignment splint reduces the pressure and
pain caused by Hammer toes and Bunions.
• specifically aligns the toe placing it in correct
position.
• The smooth cotton band with elastic property
gives secure fit around the foot.
• Its thin straps can be placed over affected toes
and the rigidity is adjustable using hook-and
loop strap.
• Unique T-strap of the splint reduces the pain of
bunion and prevents the big toe to slant over
hammer toes (or) crooked toes.
• Toe alignment splint is comfortable to wear with
casual shoes.

134


Toe Toe trainer comforts
• Trainers
flexible hammer toes. It
gives better relief against
the pain and irritation.
Toe trainer separates the
toes and aligns them to
look straight. It is an
effective item to cure
slightly movable Hammer
toes.
• The cotton-covered foam
provides secure feel to the
crooked toes.
• Toe trainer is easy to wear
and fits snugly for
efficient correction of
hammer toes.

135


HammerStraightener perfectly aligns
• The toe Toe Straightener
Hammer toes with little pressure. Its
cotton-covered loop with elasticity
holds the toe firmly in proper place
and it can be easily adjusted for stress
free movements. The smooth foam pad
molds accordingly with the foot shape
and renders superior cushioning at the
bottom of the feet. It also stops the
pain caused by hammer toes. The hook
closure present in the toe straightener
pulls down and aligns the deformed
toes to keep you always smiling.
• Hammer toe Straightener assists for
healthy feet by strengthening the toes
and forefoot muscles.

136


Prevention
• Avoid wearing shoes that are too short or
narrow.
• Check children's shoe sizes often, especially
during periods of fast growth.

137


Expectations (prognosis)
• If the condition is treated early, you can often
avoid surgery.
• Treatment will reduce pain and walking
difficulty.

138


Complications
• Foot deformity
• Posture changes caused by difficulty in walking

139


140


141


Tarsal tunnel syndrome
• the ankle version of carpal tunnel syndrome
(CTS)
• posterior tibial nerve in the ankle becomes
compressed, resulting in loss of sensation and
pain in a portion of the foot

142


143


Tarsal tunnel syndrome
• median and lateral plantar branches, which
supply the sole of the and distal phalanges, are
affected by nerve compression

• dx and treatment: same with CTS

144


145


Plantar fasciitis
• an inflammation of the plantar fascia, which is
located in the area of the arch of the foot
• common: middle-aged and older adults,
athletes esp runners

146


Plantar fasciitis

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19568.jpg

147


Plantar fascia
• A very thick band of tissue that covers the bones on
the bottom of the foot.
• extends from the heel to the bones of the ball of the
foot and acts like a rubber band to create tension
which maintains the arch of the foot.
• If the band is long it allows the arch of the foot to be
low, which is most commonly known as having a flat
foot.
• A short band of tissue causes a high arch.
• This fascia can become inflamed and painful in
some people, making walking more difficult.

148


Plantar fascia

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19567.jpg

149


Risk factors
o Foot arch problems (both flat feet and high
arches)
o Obesity or sudden weight gain
o Long-distance running, especially running
downhill or on uneven surfaces
o Sudden weight gain
o Tight Achilles tendon (the tendon connecting
the calf muscles to the heel)
o Shoes with poor arch support or soft soles

150


s/s:
• The most common complaint is pain and
stiffness in the bottom of the heel. The heel
pain may be dull or sharp. The bottom of the
foot may also ache or burn.

151


s/s
o The pain is usually worse:
In the morning when you take r first steps
After standing or sitting for a while
When climbing stairs
After intense activity
o The pain may develop slowly over time, or
suddenly after intense activity.

152


Treatment
o conservative treatment:
rest
ice - at least twice a day for 10 - 15 minutes,
more often in the first couple of days.
stretching exercises
strapping of foot to maintain arch
orthotics

153


Treatment
o conservative treatment:
heel stretching exercises
resting as much as possible for at least a week
shoes with good support and cushions
wear heel cup, felt pads in the heel area, or
shoe inserts
use night splints to stretch the injured fascia
and allow it to heal.

154


Treatment
o If these treatments do not work, doctor may
recommend:
Wearing a boot cast, which looks like a ski boot,
for 3-6 weeks. It can be removed for bathing.
Custom-made shoe inserts (orthotics)
Steroid shots or injections into the heel
NSAIDs or steroids
endoscopic surgery – to remove inflamed tissue
may be required

155

Maria Carmela 3/5/2012

L. Domocmat,
RN, MSN

Boot cast

156


Orthotics

157


Orthotic devices

158


Expectations (prognosis)
o Nonsurgical treatments almost always
improve the pain.
• Treatment can last from several months to 2
years before symptoms get better. Most
patients feel better in 9 months. Some people
need surgery to relieve the pain.

159


Complications
o Pain may continue despite treatment.
o Some may need surgery.

160


161


Ingrown Nail
• nail silver penetration of the skin, causing
inflammation
• occurs when the edge of the nail grows down
and into the skin of the toe. There may be pain,
redness, and swelling around the nail.

162


Anatomy of a toenail

163


Ingrown Nail
• AKA:
▫ Onychocryptosis
▫ Unguis incarnatus
▫ Nail avlusion
▫ Matrix excision

164


• An ingrown toenail can result from a number of
things,
• but poorly fitting shoes and toenails that are
not trimmed properly are the most common
causes.
• The skin along the edge of a toenail may
become red and infected.
• The great toe is usually affected, but any
toenail can become ingrown.

165


166


• Ingrown toenails may occur when extra
pressure is placed on toe.
• Most commonly, this pressure is caused by
shoes that are too tight or too loose.
• If walk often or participate in athletics, a shoe
that is even a little tight can cause this
problem.
• Some deformities of the foot or toes can also
place extra pressure on the toe.

167


Infected ingrown toenail

168


o Nails that are not trimmed properly can also
cause ingrown toenails.
When toenails are trimmed too short or the edges
are rounded rather than cut straight across, the
nail may curl downward and grow into the skin.
Poor eyesight and physical inability to reach the
toe easily, as well as having thick nails, can make
improper trimming of the nails more likely.
Picking or tearing at the corners of the nails can
also cause an ingrown toenail.

169


• Some people are born with nails that are
curved and tend to grow downward. Others
have toenails that are too large for their toes.
Stubbing your toe or other injuries can also
lead to an ingrown toenail.

170


Treatment
• If have diabetes, nerve damage in the leg or
foot, poor blood circulation to foot, or an
infection around the nail, go to the doctor right
away.
• Do NOT try to treat this problem at home
(Bathroom treatment)

171


Treatment
o To treat an ingrown nail at home:
Soak the foot in warm water 3 to 4 times a day
if possible. Keep the toe dry, otherwise.
Gently massage over the inflamed skin.
Place a small piece of cotton or dental floss
under the nail. Wet the cotton with water or
antiseptic.

172


Treatment
may trim the toenail one time, if needed. When
trimming toenails:
Consider briefly soaking your foot in warm water to
soften the nail.
Use a clean, sharp trimmer.
Trim toenails straight across the top. Do not taper or
round the corners or trim too short. Do not try to cut
out the ingrown portion of the nail. This will only make
the problem worse.
Consider wearing sandals until the problem has gone
away. Over-the-counter medications that are placed
over the ingrown toenail may help some with the pain
but do not treat the problem.

173


Proper and improper toenail trimming.

174


Treatment
If this does not work and the ingrown nail gets
worse, see family doctor, a foot specialist
(podiatrist) or a skin specialist (dermatologist).
removal of silver by podiatrist

175


partial nail avulsion
o If ingrown nail does not heal or keeps coming
back, doctor may remove part of the nail.
o Numbing medicine is first injected into the toe.
o Using scissors, your doctor then cuts along the
edge of the nail where the skin is growing over.
This portion of the nail is then removed. This is
called a partial nail avulsion.
o It will take 2 to 4 months for the nail to regrow

176


Sometimes doctor will use a chemical,
electrical current, or another small surgical cut
to destroy or remove the area from which a new
nail may grow.
antibiotic ointment - If the toe is infected

177


Prevention
• Wear shoes that fit properly.
• Shoes worn every day should have plenty of
room around toes.
• Shoes that wear for walking briskly or for
running should have plenty of room also, but
not be too loose.

178


Prevention
o When trimming toenails:
Considering briefly soaking foot in warm
water to soften the nail.
Use a clean, sharp nail trimmer.
Trim toenails straight across the top. Do not
taper or round the corners or trim too short.
Do not pick or tear at the nails.
Keep the feet clean and dry. People with
diabetes should have routine foot exams and
nail care.

179


180


181


Hypertrophic Ungual Labium
• chronic hypertrophy of nail lip
• caused by improper nail trimming
• results from untreated ingrown toenail
• treatment:
o surgical removal of necrotic nail and skin
o treatment of secondary infection

182


183


References
• Krug RJ, Lee EH, Dugan S, Mashey K. Hammer
toe. In: Frontera WR, Silver JK, Rizzo TD Jr.,
eds. Essentials of Physical Medicine and
Rehabilitation. 2nd ed. Philadelphia, Pa:
Saunders Elsevier;2008:chap 82.
• http://www.ncbi.nlm.nih.gov/pubmedhealth/P
MH0002215/

184


References
• Ignatavicius and Workman (2006). Medical surgical
nursing [5th ed]. Singapore: Elsevier.
• http://www.epodiatry.com/corns-callus.htm
• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH
0004438/
• http://www.bupa.co.uk/individuals/health-
information/directory/c/corns
• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH
0002217/
• http://orthoinfo.aaos.org/topic.cfm?topic=a00154

Musculoskeletal Disorders of the feet

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